To ensure that the client's respiratory status is stable upon his arrival on the medical unit, the
nurse should complete which assessment first?
Oxygen saturation
-Provides info about the effectiveness of gas exchange
Pt.'s RR is 32 BPM. What follow-up assessment data should the nurse obtain first?
Use of accessory muscles
-Indicates increased respiratory effort
-Pt. may be in respiratory distress
After answering a few questions, the client begins to cough. What assessment should the nurse
perform?
Note the amount and appearance of any sputum
After pt. stops coughing, the nurse continues the interview. To assess the client's history
related to dyspnea on exertion (DOE), what question should the nurse ask Mr. Jackson?
"What activities cause you to feel short of breath?"
Nurse asks pt. about his history of smoking. He then looks away and remarks that he is very
fatigued from answering all the interview questions.
How should the nurse respond?
Advise the client to rest in the bed while the nurse performs a physical assessment of the
client.
Ratio Anteroposterior and Transverse chest diameter is 1:1.
How should this finding be documented?
Barrel Chest
-Increased AP:T ratio
What assessment will provide supporting data related to hypoxemia?
-Color of palms and soles
--Cyanosis
-Shape of the fingers and fingertips
--Clubbing
Locating the Angle of Louis is important to guide the nurse in next locating what area?
2nd rib
-Attach to the sternum at the Angle of Louis, or sternal angle
-Point where Trachea bifurcates
Facing pts. back and placing both hands on his posterolateral chest at the level of T9.
To assess chest excursion, what should the nurse do next?
Ask the pt. to inhale deeply
The nurse observes symmetric chest excursion. What action should the nurse take?
Document the normal finding on the assessment record.
nurse should complete which assessment first?
Oxygen saturation
-Provides info about the effectiveness of gas exchange
Pt.'s RR is 32 BPM. What follow-up assessment data should the nurse obtain first?
Use of accessory muscles
-Indicates increased respiratory effort
-Pt. may be in respiratory distress
After answering a few questions, the client begins to cough. What assessment should the nurse
perform?
Note the amount and appearance of any sputum
After pt. stops coughing, the nurse continues the interview. To assess the client's history
related to dyspnea on exertion (DOE), what question should the nurse ask Mr. Jackson?
"What activities cause you to feel short of breath?"
Nurse asks pt. about his history of smoking. He then looks away and remarks that he is very
fatigued from answering all the interview questions.
How should the nurse respond?
Advise the client to rest in the bed while the nurse performs a physical assessment of the
client.
Ratio Anteroposterior and Transverse chest diameter is 1:1.
How should this finding be documented?
Barrel Chest
-Increased AP:T ratio
What assessment will provide supporting data related to hypoxemia?
-Color of palms and soles
--Cyanosis
-Shape of the fingers and fingertips
--Clubbing
Locating the Angle of Louis is important to guide the nurse in next locating what area?
2nd rib
-Attach to the sternum at the Angle of Louis, or sternal angle
-Point where Trachea bifurcates
Facing pts. back and placing both hands on his posterolateral chest at the level of T9.
To assess chest excursion, what should the nurse do next?
Ask the pt. to inhale deeply
The nurse observes symmetric chest excursion. What action should the nurse take?
Document the normal finding on the assessment record.
